Nokea
As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
- A. Place the client in a wheelchair to protect their safety in the clinic.
- B. Remove the cane from the client to protect their safety.
- C. Teach the client about the proper length of a cane.
- D. Have the client use a wheelchair rather than the cane.
Correct Answer: C
Rationale: Teaching the client about proper cane length (handle at wrist level when arm is relaxed) promotes safe and effective mobility.
You may also like to solve these questions
The client scheduled for a transurethral resection prostatectomy (TURP) asks the nurse to explain how the prostate is going to be removed. The nurse should tell the client that the prostate will be removed through which pathway?
- A. The urethra
- B. A lower abdominal incision
- C. An upper abdominal incision
- D. An incision made in the perineal area
Correct Answer: A
Rationale: A TURP is done through the urethra. An instrument called a resectoscope is used to remove the tissue using high-frequency current. A lower abdominal incision is used for suprapubic or retropubic prostatectomy. An upper abdominal incision is not used. An incision between the scrotum and anus is made when a perineal prostatectomy is performed.
A client diagnosed with glomerulonephritis and at risk of developing acute kidney injury should be monitored for which complication?
- A. Bradycardia
- B. Hypertension
- C. Decreased cardiac output
- D. Decreased central venous pressure
Correct Answer: B
Rationale: Acute kidney injury caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of acute kidney injury is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. Acute kidney injury from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for renal failure.
The nurse is caring for a client with a nasogastric tube in place for decompression. Which of the following actions is most appropriate to ensure proper functioning of the tube?
- A. Irrigate the tube with 30 mL of sterile saline every 4 hours.
- B. Keep the head of the bed elevated at 45 degrees.
- C. Check for tube placement every shift.
- D. Clamp the tube when ambulating the client.
Correct Answer: C
Rationale: Checking tube placement every shift ensures the nasogastric tube remains in the stomach, preventing complications like aspiration.
The nurse monitors the serum electrolyte levels of a client who is taking digoxin (Lanoxin). Which of the following electrolyte imbalances is a common cause of digoxin toxicity?
- A. Hyponatremia.
- B. Hypomagnesemia.
- C. Hypocalcemia.
- D. Hypokalemia.
Correct Answer: D
Rationale: Hypokalemia enhances digoxin's effect on the heart, increasing toxicity risk by altering cardiac membrane potential.
In preparing a plan of care, which is the priority intervention to address the needs of a client recently assaulted sexually?
- A. Providing instructions for medical follow-up
- B. Obtaining appropriate counseling for the victim
- C. Providing anticipatory guidance for police investigations, medical questions, and court proceedings
- D. Exploring safety concerns by obtaining permission to notify significant others who can provide shelter
Correct Answer: D
Rationale: After the provision of medical treatment, the nurse's next priority would be obtaining support and planning for safety. Option 1 is concerned with ensuring that the victim understands the importance of and commits to the need for medical follow-up. From the options provided, this is not a priority intervention. Options 2 and 3 seek to meet the emotional needs related to the rape and emotional readiness for the process of discovery and legal action.